CPCS Credentialing Information Management 4 — Questions and Answers
Question 1: A provider fails to disclose a prior malpractice settlement on their initial application, which is later discovered during NPDB query. How should this be classified?
- A minor administrative oversight with no consequences
- A material misrepresentation that must be reported to the medical staff committee (Correct answer)
- An error to be corrected at next reappointment only
- A breach that requires immediate notification to the state licensing board
Correct answer: A material misrepresentation that must be reported to the medical staff committee
Failure to disclose a malpractice settlement is a material misrepresentation and must be referred to the medical staff committee per standard credentialing policy.
Question 2: Which element is NOT typically included in a credentialing application for a new physician?
- Work history for the past ten years
- Personal financial statements (Correct answer)
- Malpractice insurance coverage details
- References from current or recent clinical colleagues
Correct answer: Personal financial statements
Personal financial statements are not a standard component of a physician credentialing application.
Question 3: Under URAC standards, which of the following is required for a delegated credentialing arrangement?
- The delegating entity may transfer all oversight responsibilities permanently
- A written delegation agreement and periodic oversight audits of the delegate (Correct answer)
- The delegate must use only paper-based records
- Delegation is permitted only for physicians, not allied health professionals
Correct answer: A written delegation agreement and periodic oversight audits of the delegate
URAC requires a formal written delegation agreement and ongoing oversight audits to ensure the delegate meets the delegating entity's standards.
Question 4: A credentialing specialist is asked to set up a flagging system for providers approaching license renewal. What is the best practice lead time for sending the first alert?
- One week before expiration
- One month before expiration
- 90 to 120 days before expiration (Correct answer)
- Only on the day of expiration
Correct answer: 90 to 120 days before expiration
Best practice is to alert providers 90 to 120 days before expiration to allow sufficient time for renewal without lapsing privileges.
Question 5: A physician requests access to their own credentialing file. What is the correct response?
- Deny access because credentialing files are always confidential
- Allow access to their own file per organizational policy, excluding peer references if protected (Correct answer)
- Require a court order before any access is granted
- Provide access only after removing all primary source documents
Correct answer: Allow access to their own file per organizational policy, excluding peer references if protected
Providers generally have the right to review their own credentialing file, though peer reference letters may be protected from disclosure per organizational policy.
Question 6: Which of the following credentialing data elements should be verified through the Office of Inspector General (OIG) exclusion database?
- Board certification status
- Graduate medical education completion
- Exclusion from federal healthcare programs (Correct answer)
- Malpractice insurance policy limits
Correct answer: Exclusion from federal healthcare programs
The OIG List of Excluded Individuals/Entities (LEIE) must be checked to confirm the provider has not been excluded from federal healthcare programs.
Question 7: When a credentialing file is transferred from one facility to another as part of a hospital merger, what must the receiving organization do before relying on the transferred file?
- Accept the file as complete since it was already verified
- Review the file for completeness and re-verify any credentials that have expired or are near expiration (Correct answer)
- Restart the entire credentialing process from scratch regardless of the file's age
- Request new peer references only and rely on all other existing verifications
Correct answer: Review the file for completeness and re-verify any credentials that have expired or are near expiration
Receiving organizations must review transferred files for completeness and re-verify any lapsed or soon-to-expire credentials before relying on them.
CPCS Credentialing Information Management 4
A provider fails to disclose a prior malpractice settlement on their initial application, which is later discovered during NPDB query.
How should this be classified?